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s SAN JOAQUIN LOCAL HEALTH. DISTRICT 1 <br /> FOR OFFICE USE: 1601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�-le �ffcr <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued -�-J6 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Focal Health District for a permit to construct' <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of -the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name 7 Phone <br /> Address d City <br /> Contractor's Name ! - - License ��� Phone ' <br /> i <br /> TYPE OF WORK (Check) : NEW WELL `/ / DEEPEN '/ / RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT / <br /> Other / /. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL ,CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool. Dia. � of' Well Excavation <br /> Domestic/private Drilled Dia. - of Well Casing <br /> Domestic/public Driven_ ,.�,. _ .Gauge of Casing <br /> Irrigation Gravel Pack._ _Depth of Grout Seal <br /> Cathodic Protection Rotary-• ' Type of Grout <br /> Disposal Other Other Information ' \j <br /> Geophysical Surface� Seal Installed By: - - <br /> f f <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. i <br /> PUMP REPLACEMENT: /' State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Desdribe Material. and Procedure t <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a ; <br /> WELL DRILLERS REPORT of the well and notify them before putting the -well in use. The above <br /> information is true to the best of my. knowledge and belief. I WILL FOR A GROUT INSPECTION <br /> PRIOR TO G UTING FINAL INSP CTION. <br /> SIGNED TITLE <br /> DRAW Ph T PLAN 'ON REVERSE SIDE) <br /> FOR DEPARTMENT, USE ONLY <br /> PHASE I p <br /> APPLICATION ACCEPTED BY DATE 7- <br /> ADDITIONAL <br /> ADDITIONAL COMMENTS: <br /> PHASE II GR PECTION-- _PHA Ems. I/ IN -INSPECTION-.' <br /> INSPECTION BY ATE _. INSPECTION BY '�/C DATE <br /> _. . <br /> E H 1426 Rev. 1-74 ! 376 2M <br />